Reply turned post: The nightmarish vision of a baby-friendly hospital

Feministe, along with a few other things I've seen around the interwebs, has a hand-wringing post about New York City encouraging hospitals to adopt baby-friendly practices such as limiting staff access to formula, not advertise formula, not give free formula samples, etc. Caperton at Feministe describes this state-controlled gulag:

Starting September 3, baby formula will be a controlled substance at some New York City hospitals. Under the health department’s voluntary Latch On NYC program, 27 hospitals are literally hiding the baby formula under lock and key, tucking it away in distant storerooms and locked dispensaries like legitimate medications that need to be tracked. Nurses will be expected to document a medical reason for every bottle a newborn receives, and mothers will get a breastfeeding lecture every time they ask for a bottle of formula.

Cue lots of upset in the comments about how babies will go hungry.

My first response:

So many of these comments are ridiculously overdramatizing an already overdramatized issue. “Babies will be forced to wait an hour for a bottle!” No. I work as an LC at a hospital with these policies so let’s clear some things up:
1) You don’t want to breastfeed, you don’t. You get your bottles on admission and that’s the end. The LC doesn’t see you unless you ask to be seen for some reason, like engorgement.
2) You want to breastfeed, you breastfeed. Nurses can’t sneak formula behind your back. Before we started documenting the mother’s consent, there was a lot of “she said/she said” after the night shift left. The nurse claimed the mom asked for a bottle, the mom claimed the nurse gave it without permission. Now if there’s a bottle, everything is documented and no one can say they didn’t know.
3) You need a bottle, the nurse or NA brings it to you. There’s no “queue” and no one is waiting for an hour. The formula is in the cabinet with all the other supplies. (That is totally staff-facing by the way – it’s not like the parents ever know it’s locked up. So is the Tylenol and that’s not shaming people with headaches.) We limit the amount of formula we give per feeding in part because people will give insanely inappropriate amounts. A newborn has a stomach made to hold about a third of an ounce at birth. I have seen people give over two ounces at one feeding!! It’s considered an accomplishment by grandma that she got the baby to eat so much, but it is not good for the baby.
4) If you are asking for formula for personal reasons, we document the reason. If the baby needs it for medical reasons, we document that too. Again, this is not to shame anybody or demand they give us a good excuse, it is to push the medical/nursing staff to acknowledge that “the baby cried some” is not a reason to tell the mother “you need to formula feed or your baby will starve”. (You think people don’t do that? You are wrong.) Medical reasons to supplement include excessive weight loss, jaundice associated with poor feeding, etc.
5) No one gets lectured. The consent they sign does say that giving bottles may interfere with their STATED plan to breastfeed. That is the truth, so I don’t think there’s a big problem with it. I work with a lot of moms who choose to formula feed for various reasons, usually because they believe they don’t have enough milk. I disagree, and I explain why I don’t think that there is a medical need for supplementation. I say that while there is no medical need, it is their baby and they can decide whatever they want. Some parents hear my explanation, feel reassured, and keep breastfeeding exclusively. Some decide they want to go ahead and supplement. Their baby, their choice. So much for the heavy-handed police state – sorry if real life disappoints. I feel like so many of these comments are like a Tea Party vision of Obamacare.


My second comment:

@Caperton: “On top of that, we have arguments of Nurses are good and supportive and helpful and so this policy won’t have negative side effects vs. Nurses sneak formula and bottle-feed your baby behind your back and don’t honor your wishes, so they need extra rules. Whether it’s either or both…” It is both, and also Nurses can be pushy jerks about both breast and formula feeding (and a million other topics as well “stop picking up the baby when it cries!”) They do need extra rules. These are some of the rules.

 “…Whether it’s either or both, we still have a policy that’s based on locking up baby formula and dispensing it bit by bit like feeding a baby bird, rather than on treating new mothers like adults: educating them about breastfeeding, letting them know that support is available, and then trusting them to make their own choice. And then honoring that choice.” But see this is where I don’t get it. How does the status quo honor people’s choices? We DO have breastfeeding moms getting the runaround and staff disrespecting them. This policy is meant to address that. In the meantime, everyone still gets what they want. This obsession about the locking up is still so puzzling to me. No mother could ever go and help herself to the formula cabinet. She always had to call the nurse to get formula brought to her. The lock is for the STAFF. And actually, feeding a baby human IS like feeding a baby bird (except for the worms part). They only need very small amounts. And they are OK if you bring them one meal at a time; they don’t know or care where the next meal is stored.

Finally, I am ALL FOR maternity leave. This is a HUGE and important component of breastfeeding support. And you better believe breastfeeding advocates know it and talk about it A LOT. It doesn’t mean that the hospital isn’t important too, and is a place where public health officials can actually make a concrete, immediate difference. People who are sabotaged in the hospital don’t ever make it to 2-3 months out as it is. I did some number-crunching for a WIC office and 50% of their moms who initiated breastfeeding stopped in the first two weeks. There is a huge drop-off after the much-vaunted 90% initiation, and that actually starts in the hospital for many people.


In response to continued upset about the locked formula: 

@Lauren: “That’s a staff education issue, not a mother education issue. It’s not resolvable by locking up baby food.” Again, locking up the formula is PART of what they are doing for staff. When you call for a bottle, do you know if the nurse has to deal with a lock or not? Nope. But she can’t be snagging bottles left and right for moms who don’t want them. Staff education is also part of that; it’s still just so puzzling to me that people are acting like the baby itself will have to open a bank vault to get fed.

Now this evening an update to the original post: 

*Update 8/1, 6:30 p.m. According to Samantha Levine, deputy press secretary in Mayor Bloomberg’s office, the information on the Latch On NYC site was wrong, and hospitals will not be expected to keep formula locked away (although they’re free to do so). She says they’re correcting the FAQs to reflect that. It seems like a rather a strange thing to get so diametrically incorrect, but removing the lock-and-key element of the Latch On NYC initiative does help things immeasurably.

---

 ??? I do not get it. This is what our scary locked formula storage looks like. It's in the nursery.

You type your login, hit a few buttons, and open the door. FYI, the breast pump kits, nipple shields, etc. are in this too. It helps the people who restock track the par levels so they can keep any supplies from running out. No one is upset that because those things are locked up, they're discouraging breastfeeding.

Can anyone help me understand all the drama over the locked cabinet requirement, which once removed has "helped things immeasurably"? I'd say out of all the things commenters were concerned about (shaming, lecturing) it is the least relevant. Ask any of our patients who use formula whether we keep it behind a lock (besides the lock on the nursery door) and I guarantee not a single one will know. Is it just some kind of gut feeling?

Which part of baby-friendly do you have a problem with?

So since I wrote my screed, more has happened (all forwarded to me by the endlessly helpful Beth!) At the end of my last post, I linked to a post by Gina at Feminist Breeder called "Why I am a Feminist AND a Lactivist", responding to Jessica and talking about why she supports Baby-friendly. Apparently some Twitter activity around the past happened (I try to stay off Twitter - I'm already addicted to the Internet enough as it is!) Then Jessica Valenti wrote a response to the tweets (hard to tell if she actually read Gina's post). Jessica said:

I’m sympathetic to Catilin’s argument that there are problems with the way that formula companies market their products (there’s quite a long history there). That said, of course free formula in hospitals is done from a marketing perspective, not for the good of women. Companies are companies and they’re targeting their audience. But I’ll tell you what - when my breastmilk ran out while Layla was in the NICU, I was sure as shit glad there was formula there to feed her. ...

But the marketing/corporate aspect was not really what Hearts’ post and my response was about - we were addressing the hypocrisy of judging women who choose to formula feed and the way they are made to justify their choice. In this case, the fact that the hospital would make formula available to women who “medically” needed it - what constitutes medical need? And what if women simply didn’t want to breastfeed? Isn’t that her right, and shouldn’t she be equally supported for that decision in the same way a breastfeeding mom is?

Except, you know, that wasn't what Jessica's original post was about. Maybe that's what she THINKS it was about, because it triggered feelings around formula feeding, breastfeeding, guilt, shame, expectations, etc. But her original post was about Baby-friendly, and criticizing hospitals for "denying" women the opportunity to use formula. Gina was pointing out that she was incorrect; Baby-friendly is about denying formula companies the opportunity to use hospitals for marketing purposes, and getting hospitals to adopt best practices to support breastfeeding.

But Jessica also covers that in her second post (which is confusing because she also said in the second post that's not what the debate was about), and says she thinks limiting formula marketing is paternalistic:

... the argument that women are “vulnerable” to free formula is just plain insulting to women’s intelligence. I trust women to make their own decisions.

As Gina points out, that's not the case for a lot of other marketing efforts that feminists take issue with:

Feminists are constantly calling out “Pregnancy Crisis Centers” for being predatory. They snag women who may be alone, scared, and confused by a major reproductive choice, and they offer them freebies to gain their trust. They tell them they’re helping them make a decision about parenting, but what they’re really doing is piling their Anti-Choice agenda on them, promising the mothers they’ll help, and then vanishing when it comes time to foot the costs of raising this baby. Feminists recognize that these centers are preying on a woman during a vulnerable time in her life. We’re not saying these women are stupid or that they’re being duped. We’re not saying that one choice is better than the other. We’re saying that the marketing is absolutely unethical.

Feminists are constantly calling out and boycotting the beauty industry for shaming women about their bodies, their lifestyles, and their choices. Why do we do that IF we think women are immune to marketing influence? Isn’t a woman smart enough not to fall for that “skinny is better” imagery? Don’t we trust her to recognize the airbrushing for what it is?

I am very curious to see how (and if) Jessica responds to that argument. But in the meantime, let's move on to her conclusion:

Listen, I support breastfeeding women - long before I had my daughter I was blogging about the heinous lack of resources for breastfeeding mothers and the various ways they are discriminated against. I think we need mandated paid maternity leave, insurance that pays for lactation consultants and breast pumps, employers who are required to have a space and breaks for pumping moms, hospital- and state-funded breastfeeding support groups and more. But I also believe that formula feeding your child is just as valid and healthy a choice as breastfeeding - it’s not something women should have to justify or be denied resources for or access to.

I agree with her! Breastfeeding women deserve time, space, resources, and support? yes! Formula feeding as valid a choice as breastfeeding? Yes! As healthy or even MORE healthy than breastfeeding? Yes, sometimes! Should you have to justify it to anyone else? No! Should you be denied resources for formula feeding? No! Wow, look, me and Jessica agreeing on everything. Except the part where she slams me, the organizations I work with, and the work that we do. Because she still thinks Baby-friendly can "suck her left one". I wrote in my last post that she doesn't seem to actually understand what Baby-friendly is. But maybe it didn't get through. So here's a little review for Jessica Valenti and anyone else who's confused:

Here are the Ten Steps to Baby-Friendly, from the UNICEF Baby-Friendly page.

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7. Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

The Ten Steps prevent hospitals from doing things like routinely supplementing breastfed babies, not training their staff, routinely separating new babies from their mothers, and trying to force babies to feed on a schedule. Good stuff, right? So where is the issue here?

The current debate seems to center around Step 6, Give newborn infants no food or drink other than breastmilk, unless medically indicated. This is an international guideline, and in the U.S. Step 6 has been reworded as "Give breastfeed newborns no food or drink other than breastmilk, unless medically indicated." As the U.S. has a long history of formula marketing via hospital, Baby-Friendly USA has added this clarification to Step 6:

The Baby-Friendly Hospital Initiative supports the International Code on the Marketing of Breast-milk Substitutes ("WHO Code"). The WHO Code stipulates that health care facilities and professionals neither accept nor offer free or low-cost substitutes for human milk. In keeping with the Code, the Baby-Friendly Hospital Initiative asks facilities to purchase all infant formula in the same manner as it purchases all other supplies. Additionally, facilities should not give infant formula samples, literature, or other items bearing the name of an infant formula product to breastfeeding mothers.

Since the original story was about a UK hospital, I looked up the UK guidelines and found their page on Step 6. They have not reworded the guideline from the international version; they have set out the following criteria for following it:

No food or drink other than breastmilk should be given to breastfed babies unless:
- there is an acceptable clinical reason, the baby is unable to breastfeed and there is no/insufficient breastmilk available
- the mother has made a fully informed choice to feed her baby other than from the breast.

No promotion for infant food or drink other than breastmilk should be displayed or distributed to mothers or staff in the facility.

The hospital in the article that sparked all this seems to have drawn ire for asking mothers to bring in their own formula if they decide to formula feed without a clinical/medical reason. But that requirement is not part of Baby-friendly. It's not required in the international guideline, or in the U.S. interpretation, nor in the U.K. interpretation. This hospital has chosen to make this change part of going Baby-friendly, but it is not required. I said in my original post that I thought that whether was a good idea or not was a legitimate subject of debate, but it is not actually being made the subject of THIS debate. Instead I'm seeing people call Baby-friendly shaming and lump it together with the anti-formula douchery on Twitter and that's just plain wrong.

Saying, as Jessica Valenti did in her original post, that "refusing to give mothers access to formula is not “baby friendly” or helpful - it’s shaming and in some cases could be very dangerous" shows that she REALLY didn't understand what Baby-friendly was about, since apparently she never saw "unless medically indicated" in Step 6. No Baby-friendly hospital would put a baby in a "very dangerous" situation by denying them formula. "Medically indicated" is how we avoid "very dangerous". It really bothers me that someone would imply that LCs, nurses, and doctors and those hospitals would shrug and say "Sorry, no breastmilk no eat!"

I made this point before and I make it again now: Baby-friendly is not about you needing to justify your choice to formula feed to hospital staff. It is about the HOSPITAL having to justify its OWN reasons for supplementing breastfed babies. Yes, that hospital in the U.K. differentiates between medical and elective supplementation, and asks the elective supplementers to bring in their own formula, and that may seem judgy and we can talk about that. But let's talk about it WITHOUT bringing Baby-friendly into the mix and WITHOUT implying that health care professionals are starving babies.

I'm glad formula was there for Jessica's baby. I'm glad she likes formula feeding and that it was a healthy choice for her. I'm really sorry people are jerks about how women feed their babies. I just don't see the connection between all those things and Baby-friendly. As I said in my last post: they are different things. Jessica had the opportunity to say "Hey, I get what Baby-friendly is, I just have a problem with this part of it and let's talk about that", but instead off we go on the mommy-wars train to Stopjudgingmeville, complete with opportunities for self-proclaimed lactivists to show off their ugliest, judgiest sides. I get so depressed by how so many feminists hop on this train unquestioningly. Back to my conference proposal in an attempt to encourage more people to think about this in a more critical way...

Another screed on breastfeeding & guilt – this time with cussing!

Oh, this comes at a great time. This comes at a PERFECT time. I was literally in the middle of writing a conference proposal for a presentation on breastfeeding as a reproductive right, and I check my e-mail. My friend (thanks for loving Internet drama, Beth!) had forwarded me the following links on breastfeeding and baby-friendly:

The first was from a feminist blog called the F Word, by a guest blogger named Laurie Hearts, "Baby friendly - but is it woman friendly?":

Manchester's largest maternity unit, St Mary's, is set to become a Unicef-approved 'Baby Friendly' hospital by ceasing to provide free formula milk to the women who give birth there. ... Women who choose to formula feed at St Mary's will have to bring their own ready prepared milk in cartons from this November; powdered milk will be banned for health and safety reasons. ...

In an era when many feminists are (in my opinion rightly) dismayed by the suggestion that a woman's right to an abortion should be subject to conditions, I have been shocked by the high level of acceptance when it comes to the notion that women who formula feed should be forced to justify their choice, not only to medical staff, but to pro-breastfeeding women. While I have never seen anyone claim that formula is better than - or even equal to - breast milk, a large number of women are vociferously and uncompromisingly against a woman's right to choose formula milk. I have witnessed a sizeable number of women, some of whom are self-declared feminists, debating on one another's social media profiles and calling for formula to be made illegal.

The second was from Jessica Valenti's blog:

[F]or me, formula feeding was absolutely, 100% better than breastfeeding. Like, life changing better... refusing to give mothers access to formula is not "baby friendly or helpful - it’s shaming and in some cases could be very dangerous. Enough already.

I usually don’t swear very much on my blog (real life is a different story) but like all good screeds, this was written while I was feeling just a little riled up. So: Holy shit. Let’s just make this clear: baby-friendly is not about preventing you from formula feeding. I work in a hospital that is pursuing baby-friendly certification. Most women at our hospital plan to breastfeed. Some women plan to formula feed. A fairly significant percentage of the breastfeeders choose to use formula at some point. The straight-up formula feeders never hear a word about breastfeeding from us. You told us on admission you planned to formula feed, here are your bottles. The breastfeeders who need to use formula for medical reasons – and they are very clearly outlined, including hypoglycemia (low blood sugar) and excessive weight loss – get formula too (and we are very fortunate to be able to offer them the option of donor milk if they are not comfortable with formula.) The breastfeeders who ask to use formula – this happens not infrequently, often because “I think I don’t have enough milk” – get education and discussion, sign a consent form, and then are given formula too. (No, we don’t have them bring in their own formula like the hospital profiled; we can debate whether that’s any different from making them bring their own baby clothes, but I think there’s a legitimate debate there.)

However, while I have a lot of respect for Jessica Valenti, she and the other blogger are completely mischaracterizing the issue here. Baby-friendly is not part of the mommy wars, and I honestly think it is irresponsible to do so. What makes hospitals baby-friendly is not preventing women from choosing formula feeding, or refusing to give them formula when their babies need it. Baby-friendly is not about forcing mothers to do anything. Baby-friendly is about preventing HOSPITALS from shoving bottles and pacifiers into breastfed babies’ mouths and then sending their unknowing mothers home with a screaming, nipple-confused baby who won’t latch. Baby-friendly is about preventing HOSPITALS from accepting “free” formula and gift bags and samples from formula companies, turning the hospital into a shill for a for-profit company, and engaging in practices that research has shown make it less likely for women to reach their own breastfeeding goals. Baby-friendly is about forcing HOSPITALS to offer regular breastfeeding education to all their staff, including nurses and doctors, so they can help mothers and not give them crap advice. Baby-friendly is not about the mommy wars. It is not about trying to force any mother to breastfeed. It is about changing HOSPITAL practice, and whether or not you realize it, most hospitals in the U.S. have a long, long way to go. Baby-friendly is about offering evidence-based care to promote health.

“Who are you to decide that breastfeeding promotes health? Formula feeding can be lifesaving!” Hell yes it can. You think I don’t see that? I see that all the time. When women are dealing with a new baby, sleep deprivation, hormone shifts AND feeding issues, you are dealing with a potent cocktail for severe depression – you think I never meet women with serious PPD? You think I don’t see women with intense pain from feeding, or a history of low supply, or a baby who isn’t transferring milk well? You think I don’t see women who are BBAC (breastfeeding baby after challenges), who are having the same issues as their last hellish breastfeeding experience, where we talk through their situation and their emotions and their individual needs and they decide that on balance, formula feeding is the healthiest thing for them and their babies? You think I don’t see women with insufficient glandular tissue to make enough milk, whose babies will starve without supplementation? That I never meet women, like Jessica Valenti, who had life-threatening health issues and premature deliveries, who are pump dependent and struggle to make even a tiny supply? You think that because I work at a baby-friendly hospital I refuse to let any of those women use formula? Of COURSE I do. Of COURSE formula is lifesaving. And it doesn’t NEED to be lifesaving to be OK. I see women who just decide that breastfeeding isn’t for them. They don’t want to breastfeed. Maybe they said they wanted to because they wanted to give it a try, but they’re not that into it. I shrug and move on. As a lactation consultant and public health professional, I would love for more women to choose to breastfeed. The lady in Room 4 doesn’t want to? We gave her the spiel, and it’s her choice.

So “formula-should-be-illegal” Judgy McJudgersons out there (even though I think there are fewer of them out there than their reputation): Shut up. Yup, I said it. You can never know what’s really going on in a woman’s life. When you demand that a woman give you a good reason for not breastfeeding, you have no clue what you’re asking. How about this: “Well, I was sexually abused as a child and I had very frightening flashbacks every time I breastfed.” Is that the reason you need to hear? Women don’t need to justify their feeding choices to you. They don’t need formula to be made illegal “for their own protection”. Because even if a woman doesn’t have a “good”, “morally correct” reason to breastfeed (just like many women do not have “socially approved” reasons for having an abortion), “I just didn’t want to” is reason enough. “But if they were really informed – ” No. I know we don’t do a very good job with breastfeeding education in this country. Please, if you really care about educating women, do not do it by asking nosy questions of your pregnant friends or of the woman with a bottle next to you on a park bench, or post judgy comments on mommy wars-fueling news articles. Lobby our elected officials to stop slashing funding for maternal and child health programs. Volunteer to teach classes at a community center. Write a letter to your local hospitals encouraging them to become (gasp!) baby-friendly.

Finally, let’s stop with the idea that women who tried to breastfeed – who wanted to breastfeed – and couldn’t breastfeed, shouldn’t be sad. Do I think they should feel guilty? That they should feel ashamed? HELL NO. But it’s OK for them to mourn something they had hoped to do, and couldn’t. It’s also OK for them NOT to mourn it, to just accept it and go on, to appreciate the things about formula feeding that are positive for them. Everyone is different. But women who had looked forward to providing milk for their baby, who planned to have a positive nursing relationship with their baby, can feel sad about the loss of those hopes. That does not mean that “boob nazis” made them feel guilty and should just stop it with the baby-friendly bullshit already. It doesn’t mean that formula is supernifty and that we should let formula companies engage in deceptive marketing practices and co-opt hospital staff. It means we should support those women and help them work through their sadness so that they can move forward feeling good about themselves as mothers. It means that we should work harder to offer donor milk so that if those mothers are helped by knowing their baby is still getting breastmilk, they have the option to choose it. It means we should continue to research ways to help women so that they ARE able to reach their breastfeeding goals.

I am just tired of this argument. I’ve said it before, and I’ll say it again: when we hate on breastfeeding initiatives like baby-friendly, we hate on the very things that make it possible for women to breastfeed. An individual woman’s feelings of being judged or of guilt are REAL issues that deserve their own space and time (that’s why I just gave them their own paragraphs). But they are not the same thing. They are different. Different things. The end.

(As I was finishing this up, I saw that Gina at the Feminist Breeder has also written a post prompted by those blogs, "Why I’m a Feminist AND a Lactivist", and I highly encourage you to go and check it out.)

Follow-up: who should get donor milk?

So a while back I posted a question of who should be offered donor milk in the hospital. I was curious to see what people thought, and follow up with my own thoughts and current practice. I've been letting that follow-up languish, and the recent discussion about milk donation has finally nudged me into finishing it up. Here we go!

The comments were very interesting, and there seemed to be two main themes to the answers:

1) Only babies whose mothers are trying to produce breastmilk for them but are not able to (e.g. supply issues, adopted babies, etc.) should be offered donor milk

As Christie B. said:

...I have a hard time thinking that donor milk should be provided for free to women who are not trying their best to provide their own milk (if not contraindicated) for their own babies. If there is a medical issue, it makes sense for donor milk to be covered like a pharmaceutical but otherwise donor milk seems like a luxury good/service, like eating out instead of cooking.


2) Every baby should be offered donor milk as an alternative to formula, no matter the reason for supplementation (so even if mom is just not willing to breastfeed, the baby should still receive donor milk).

Burrowing In was of this mind:

As a mother whose baby was blessed by donor milk, I want to say that every baby should have access to it if necessary. Forget the mothers and their intentions and their shortcomings and their socioeconomic status. BABIES deserve that milk!


There were also ways to combine these two answers to some extent.

For example, Jespren suggested:

I feel that 1st dibs on donated breastmilk should go to NICU babies whose mothers have supply issues or have dried up and are unable to produce milk. Next I think it should be offered to mothers of healthy babies who can't physically produce any/enough milk. (This would include adopted babies whose new moms can't lactate) finally, if there is still milk availible, it should be offered to babies whose mothers chose not to breastfeed. ... But, for moms that have no physical reason not to breastfeed, they should have to purchase it, preferable at the same cost as formula. (I don't understand for a moment why DONATED breastmilk is so prohibitively expensive once it goes through a 'milk bank')*

So this prioritizes the babies who receive donor milk based on a judgment of BOTH the baby's need AND the mother's intent. Any babies whose mothers intend to breastfeed are prioritized over babies whose mothers don't intend to breastfeed.

Another comment comes from Molly who poses two questions, both of which I think are excellent:

The post's title asks two 'to whom' questions: "Who should get donor milk? Who should it be offered to?" In considering these questions, we should probably ask what 'whom's we mean: postpartum women, babies, families? You can't exactly offer a medical option to a baby, so in the second case presumably we mean the baby's parents (why only mothers, as some responses seem to suggest?). In the first question, the implication seems again to be that parents/mothers are the ones getting the milk: does it make any difference if we reconceptualize the question to mean, explicitly, 'which babies deserve access to donor milk (rather than formula)?'

This is a big piece that I struggle with. When we focus on the mother's intent, we're really asking which mothers deserve to get donor milk - not which babies. If one mother can't produce milk and one just doesn't want to, why is the first baby (not the mother) more deserving of donor milk than the second baby? Furthermore, it quickly becomes a tangled web of hairsplitting over who is "really" deserving. To tread into more politically controversial territory, over and over again I keep thinking of how it reminds me of debates on abortion and philosophical and legal attempts to determine which women are "deserving" of an abortion - women who are victims of nonconsensual sex? women who "just made a mistake this once"? etc.

In those abortion debates, I think it quickly becomes clear that it is not so much about abortion as it is deciding who is "good" and deserving of help, and who is "bad" and needs to "deal with the consequences". Similarly, trying to decide who deserves donor milk could easily be a twisty path. It's easy enough to think about a mother who says, "I'm not going to breastfeed, it's too hard, just bring me bottles of milk that some other woman has pumped" and decide that she'd be abusing the availability of donor milk, but in life, as usual, there are a lot more gray areas than black-and-white.

What about the NICU baby's mother who has a low supply, but it's low because she only pumps four times a day (knowing that she should be pumping more)? What if she only pumps four times a day because she has several other young children at home, and one has special needs? What if she's so exhausted by pumping and only getting 1/2 an ounce per session that she quits entirely? Would you feel differently if she had breastfed all of her other children for a year each, or if she had not breastfed them but had planned to breastfeed this baby, or had not planned to breastfeed this baby but changed her mind when it was born prematurely?

Or what about the mother of a healthy term baby who has a borderline supply, and has nursed and pumped diligently to keep her supply up but needs to supplement several times a day? What if she is offered medications that could bring her up to full production but declines them? Would you feel differently if she was declining them because she had a history of depression and was worried about side effects, or because she just doesn't like to take medications?

There's an element of thought experiment in some of this - in our current situation, generally only the most motivated moms who have exhausted all their resources seek out donor milk for long-term use outside of the hospital. Still, if we are aiming towards a future in which donor milk is more abundantly available to all, it's worth thinking about and examining our own assumptions about who "deserves" milk.

In the hospital, we can edge around this debate to some extent. For a healthy full-term baby the supplementation will generally be short-term (until the blood sugar stabilizes, until her milk comes in, etc.). If the mother is planning to exclusively breastfeed, we can argue that we are avoiding harmful effects on the infant gut of even a small amount of formula, assuming that soon the mother's own milk will be taking over and will be all the baby receives.

On the other hand, if the mother is planning to do some mixed feeding from very early on (as many mothers tell us they plan to do), there seems very little point in protecting the gut since they'll receive formula early on regardless.

But the way this plays out in practice makes Molly's second question very relevant:

How does class privilege play out here? Education, internet access, reading literacy, technological literacy, financial ability to purchase (and leisure time to read) books, access to high-quality mother-centered prenatal care, etc., etc.? If anyone can ASK for donor milk, should my baby get human milk simply because I'm an overeducated overprivileged English-speaking birth junkie who knows to ask the secret right question? Or, if limits on offering ought to be imposed (according to some standard of need or worth or whatever), is there any way to counteract that injustice?

Class and culture absolutely play out here, particularly in cultural terms, which are both linked to racial/ethnic background and to class. Most Hispanic moms tell us they are planning to do breast and formula, and are frequently asking for formula supplements on the first day (sometimes as soon as they come over from labor and delivery). Plans to supplement or switch to formula early are also common with African-American moms, younger moms, low-income moms... you get the idea. In fact, what the nurse asked me was whether we could offer donor milk to mothers on Medicaid. She assumed we couldn't, because she almost never saw them receiving it (just for the record, we can). She particularly wondered about why almost no Hispanic moms were ever using donor milk. But for a Hispanic baby, if we're at the point where they've lost 10% of birth weight and have not been supplemented yet, it is almost certainly because we have already deflected at least one request for formula on the part of the family over the course of the past several days.

So that's how it plays out: if we're only offering donor milk to the moms who are planning to exclusively breastfeed for at least the first couple of weeks, we end up with a real race/class imbalance of who ends up receiving donor milk. So then we tackle Molly's question of this imbalance - is it an injustice?

Part of me says yes - that everyone who asks for or needs supplementation should be offered donor milk and formula, check one. That part of me comes from knowing that there is definitely some power/educational stuff playing out here in that there is a real difference in patient vs. medical perceptions of when the baby needs to be supplemented. We, the hospital staff, have a short list of indications for supplementation, and the most common reasons are hypoglycemia and weight loss >10%. The parents have a longer list, and the most common reasons are that the baby is fussy even after breastfeeding for a long time, and the perception that the mother does not have enough milk. A mother does not necessarily plan to supplement with formula because she thinks it's better than breastmilk - she just thinks she won't have enough breastmilk (and since she has no idea that donor milk is available we have no idea if she would request that instead.) The more highly educated birth junkie types are much more aware of, and confident in, the fact that colostrum is generally all the baby needs for the first 2-3 days. They might need reassurance when the baby is fussy, but are willing to go with the medical staff's interpretation of baby's need for supplementation, whereas people from other cultural backgrounds are bringing their own perceptions of when the baby needs more.

So if we work with the families who really believe their baby needs something extra, and if we can't convince them of our worldview (that the baby is fine), do we do the baby and the family a service by offering donor milk? Does it emphasize the importance of human milk and avoiding supplementation with formula? Could it possibly help keep the mom from supplementing with formula in the future, once her milk is in? If we just accede to a request for formula without giving her the risks/benefits of both supplements available to her in the hospital, are we doing our own beliefs about the risk of formula use a disservice?

Then another part of me says, these families are very comfortable with formula use. They may be OK with donor milk and accept it in the hospital, but they are just as OK with formula and always will be. They will probably go straight to WIC for their first appointment and ask for supplemental formula. If we offer donor milk to those families, we are giving the babies a few more days of exclusive human milk feeding, but we are not really changing their overall situation that much, and we are using donor milk that could go to another baby. That's my view of the situation - is it reality, or is it just bias and perception on my part?

As you can see, I'm still struggling with this! Currently, I am sticking with only offering donor milk to babies with an indicated medical need, but I do generally discuss donor milk vs. formula for medically indicated supplementation even if the mother had previously talked about formula. Further thoughts or questions welcome!


* I think this reaction to the (prohibitive for most) cost of donor milk is fairly common. Having met and talked with people who run milk banks - the cost comes from the expenses of testing donors, paying for shipping, processing and testing the milk (which takes several time-consuming steps), sometimes space to physically host the milk bank, and of course materials and employees to do all of this. I have visited a milk bank - it was tiny! Just a couple little rooms and some very big freezers, and very committed mostly part-time employees. There seemed to be zero excess overhead going into this bank, and all HMBANA milk banks are not-for-profit. When all is said and done, there is a real cost to the shipping, safety testing and processing that donor milk goes through. If people are comfortable getting donor milk through a more informal route like Eats on Feets, they can absolutely get it cheaper (as cheap as free!), but they should understand what steps are being cut out of the process that are cutting the cost. Whether those are steps that are important to an individual mom, and/or important to every mom/baby/donor, is a whole separate discussion that I won't go into now!

The breastfeeding police, or how what you don't know can hurt breastfeeding mothers

Anne at Dou-la-la has a guest post up on The Leaky Boob and it is a gem. Here's a few excerpts:

YES, I do think that women who feel they ‘can’t’ produce enough milk have often been sabotaged (i.e. booby-trapped) in ways they are unaware of. And one of the things that most often thwarts them is misinformation.
HOWEVER. Statements that imply that really, everyone can breastfeed and if they didn’t succeed, they just didn’t try hard enough, mind over matter? EVERY BIT as misinformed as the bad advice that might have led a mom to undermine her supply or her belief in her supply. I know it’s highly unorthodox for a breastfeeding advocate to call other breastfeeding advocates out when their intentions really were good, but I see so much poor advice online that it’s really starting to get to me. ...


This does NOT mean that there is not a place for peer support. There so absolutely is is – La Leche League turned the tide on breastfeeding half a century ago and its very foundation was peer support. But part of being a trustworthy resource is knowing when something is beyond your knowledge – even for professionals, certain things are beyond one’s scope of practice, and it is crucial to have the honesty and humility to know when to refer.

I am a brand spankin' new IBCLC (just got my exam pass in October 2010). Before that I was trained as a breastfeeding educator (think peer counselor-type level) and as a doula, and I wrote my senior thesis on breastfeeding. I knew a fair amount about this whole feeding-babies-with-your-breast thing, I really did. But once I started training as an IBCLC, I suddenly realized how much I DIDN'T know...and when I started actually working as an IBCLC, I realized how much I STILL didn't know all OVER again. In fact, the more I learn the more I stop answering questions confidently, and instead turn to my mentor LCs (with their 5-20+ years of experience) and reference books to double- and triple-check what I THOUGHT I knew, before I give any answers. And in the meantime I hear loads of unhelpful or clueless "advice" being doled out left and right. (If I hear one more NICU nurse suggest "drinking lots of water" as a solution for low supply...)

As Anne says, this isn't a "leave it to the experts, ladies" kind of situation - there absolutely is a setting for educated, compassionate peer support and it it SO important. But let's have it be educated and compassionate - not rife with statements like "everyone can make enough milk" (I saw 2 women in the hospital this past week with classic signs of insufficient glandular tissue, and if they don't reach a full supply even with optimal milk removal, there will be a pretty darn good physiological reason that they CAN'T).

When they hear that I'm a lactation consultant a lot of people share their difficulties with breastfeeding with me (same goes for doula and birth!) I sometimes hear it as a defensive explanation, sometimes as a way of continuing to grieve/process the experience, sometimes as a simple "oh, you'll be interested in this" conversational topic. No matter what, it's hard to find a way to respond, but even when I hear something in their story that doesn't sound accurate or misguided, I try to focus on what I can simply validate and acknowledge. "Exclusively pumping is so hard, I'm impressed you stuck with it as long as you did", or "That sounds so painful, I'm sorry that happened to you". (One of my LC colleagues says, "I'm sorry things didn't work out; often people find breastfeeding is easier with the next baby" to help leave the door open for trying again in the future.)

What I don't do is ask questions or try to learn more about the situation. If a mother thinks things could have gone differently or wants to know how to change things with the next baby, she will ask me! In the meantime, support, empower, offer resources to help the mother learn more and get more advanced help - but let's stop assuming we know everything about a woman's situation, particularly after the fact. It doesn't do her any favors and it sets breastfeeding back as well.

Please read Anne's post for a thought-provoking discussion on this topic! And please share your thoughts - what do you say when a mother shares her difficult breastfeeding story? If you had challenges breastfeeding, what were helpful/unhelpful things that people said to you?

Link time! Research & investigation style

In the news and/or my e-mail inbox:

* A new book "Sanctioning Pregnancy: A Psychological Perspective on the Paradoxes and Culture of Research" by Harriet Gross and Helen Pattinson. From their description: "Sanctioning Pregnancy offers a unique critique of sociocultural constructions of pregnancy and the ways in which it is represented in contemporary culture, and examines the common myths which exist about diet, exercise and work in pregnancy, alongside notions of risk and media portrayals of pregnant women." Google Books preview here.

* The FDA will be investigating nutritional claims by infant formula manufacturers.

* When do breastfed babies need extra iron?

* The Full Spectrum Doula Network (FSDN) has several members conducting research who are looking for participants - from the FDSN newsletter:

* FSDN member Ryan Pryor is conducting a study and oral history project of queer and gender non-conforming birth workers (link here)
* FSDN member Laurel Ripple Carpenter is conducting interviews of full spectrum and radical doulas for an ethnographic study at Burlington College and Mesa State College (link here)
* FSDN member Monica Brasile is conducting an online survey of doulas for her PhD research in Gender, Women's, and Sexuality Studies at the University of Iowa. She's especially interested in representing the voices of radical and full spectrum doulas. (link here)
* Erica Varlese is conducting interviews of doulas who offer pro-bono or volunteer services or who work specifically with marginalized groups of women. (link here)

I did an interview with Laurel and it was a great experience (and I'm really looking forward to reading her final product). If you're a doula who falls into one of these categories, please consider helping out!

When and how to give formula to the developing world

Every new disaster in the developing world seems to bring e-mails to my inbox with appeals for donations, and every time one lists "infant formula" that I cringe, and ponder whether or not I should try to start a dialogue around the dangers of those donations and importance of providing them correctly.

Via the Motherwear Breastfeeding Blog, here's an example of when and how to offer infant formula appropriately: in a setting of acute medical need, under medical supervision, prepared safely and accurately by professionals, and - so importantly - in a way that is supportive of breastfeeding:

Helping Hospitals Treat Malnutrition in D.R. Congo from Action Against Hunger USA on Vimeo.

Watching the baby's eyes light up as it nursed away using the improvised supplemental nursing system reminded me so much of babies I've worked with in the hospital. We sometimes need to provide a supplement for babies who have lost more than 10% of birth weight. Often this is because the mom's milk is delayed coming in for some reason - very long labor and/or long pushing stage, or a lot of postpartum blood loss. Of course, taking the baby off the breast and giving the supplement by bottle has the potential to confuse the baby, demoralize the mom, and creates extra work for her having to pump to continue stimulating her breasts in order to get the milk in ASAP. We always prefer to use an SNS, assuming the baby is latching and nursing well - just put the baby to breast, get the suck going and then slide the tube in the corner of the mouth.

When you start the SNS you just see the babies' eyes fly open as they nurse away hungrily thinking "Hey! This is new!" A day or two of SNSing, and with all this continued stimulation mom's milk comes in, we pull the tube, and they're good to go. It feeds the baby while keeping everyone - baby and parents - breast-focused, and protects the milk supply. It's so neat to see it used half a world away for not-dissimilar purposes.

Who should get donor milk? Who should it be offered to?

Dou-la-la's post on encouraging the informed milk use of donor milk over formula supplementation got me thinking. At the hospital where I work, I have a lot of parents ask me about supplementation. They want to do los dos from the beginning, or they believe that the mother's colostrum isn't sufficient, or they're concerned that the fussy baby who wants to nurse constantly is starving, or they're tired of the fussy baby nursing constantly and just want to sleep. If they're really set on it, I encourage them to supplement at the breast vs. with a bottle, and not to give too much. If they're considering it but haven't decided yet, I do my best to educate them about risks of supplementation, including compromising future milk supply and altering the baby's gut. But in the end, it's their baby and their choice if they want to supplement.

Sometimes, I have to tell parents - even parents who don't particularly want to hear it - that we need to supplement. Because their baby has lost too much weight, or because there are latch difficulties, or because there is persistent hypoglycemia not helped by just direct breastfeeding. We do our best to supplement with only the mom's own expressed milk, but sometimes we have trouble getting enough of it out. In the end, those parents have to supplement - it's a medical necessity.

The thing is, no one at our hospital actually has to supplement with formula. We have banked, pasteurized human milk available for our NICU babies, and the term babies can access it as well if the parent requests it and gets a physician order. We don't need to ration it; the milk bank will tell us if they're running low and will ration appropriately on their own. We can offer it to anyone we want and they can use as much as they need while they're in the hospital, with the cost covered completely by the hospital, regardless of their insurance (or lack thereof). But once they go home, they have to purchase it from the milk bank directly themselves (unless they can convince their insurance provider to reimburse) or they have to find donor milk through other, less formal channels (as Dou-la-la discusses).

The other day one the nurses made an observation to me about who she usually sees using donor milk and who she doesn't. She asked if we offered it to everybody or if there was some discrimination going on. It got me thinking about it, and I talked to one of the other LCs about who gets offered donor milk and who should get offered donor milk. We had fairly similar feelings about it, but I won't say right now what we thought. I would like to ask all of you.

Since there's now a fairly active blogosphere conversation about donor milk being the ideal supplement for babies who are not being fully breastfed by their mothers for whatever reason: Who should be offered donor milk when the decision to supplement arises - for personal or medical reasons - and who should not? Why?

No BPA ban for baby bottles

My friend and political informant Adriane sent this along a couple weeks ago, and I let work and Thanksgiving get in the way of e-mail. So this news is now a couple weeks old, but still important:

Sen. Dianne Feinstein blames the chemical industry for killing her effort to secure, in the food safety bill, a ban on BPA in baby bottles and sippy cups. She said late Wednesday that a last-minute deal with Sen. Enzi to ban BPA in such items six months after the bill passed was scuttled by the chemical industry, which was able to get the support of some Republicans – she named Sen. Richard Burr in particular. Feinstein hoped to get Leader Reid’s approval to offer an amendment, but she told PULSE late Wednesday that her understanding was that he wouldn’t allow them.

“It’s very, very frustrating,” she said. “I cannot understand how a chemistry group would oppose taking out a chemical which at the very least may well impact the endocrine systems of infants because they want to make money.”

Original link here.

A breastfeeding support home visit

The last Centering Pregnancy group I co-facilitated, the other co-fac was an experienced LC. Between the two of us, we told the midwife that she should let us know when the moms in the group deliver and we would help them with breastfeeding if they need it. Unfortunately, they deliver at a different hospital in town (not the one where I work) where lactation support is extremely minimal. That hospital also tells moms things like "Just let her cry, she'll figure it out eventually" and "Don't feed your baby more often than every 3 hours" and "Don't let them nurse more than 30 minutes". As you can imagine, a lot of breastfeeding problems result... not to mention jaundice readmits.

One of our Centering moms had help from the midwife at the hospital (including her jaundice readmit), and from the LC once at home. Baby would not latch consistently, and the LC e-mailed me today to say that she thought things had been going better but she had just found out they weren't. She was booked. Could I see this mom today?

It was good timing - I didn't work last night - so I called the mom and headed over. Pulling in to the apartment complex and going into her apartment was a total flashback to my AmeriCorps days* - three immigrant families packed into a single apartment, each with one bedroom of their own. The bedroom was even just like I remembered, cramped with a big TV in the corner.**

We spent a long time working on feeding, pumping, and talking about our plan. She has two problems - getting her baby to latch and maintaining a supply with just a hand pump (which wasn't getting used often enough). This mom told me her goal is "puro pecho" which if you've read my "los dos" post, you know isn't always the case with Hispanic moms! I am so determined to help her reach her goal - she is a committed mom who has been persistent where other people would have given up.

Still, it made me discouraged. A more privileged mom would hopefully have the education and resources to quickly identify breastfeeding problems and feel entitled to help; she would be able to hire a private lactation consultant to make multiple home visits; she would be able to rent a hospital-grade pump to maximize her supply.

This mom happened to do Centering and happened to have for facilitators two LCs with extra time on their hands. What about all the dozens and hundreds of other moms in her situation, who we don't know and can't see? In many other counties, I could refer her to a WIC peer counselor; her county's WIC has none and doesn't seem interested in getting any. At best she might be able to get a better pump from WIC (which she didn't realize - I knew to call and ask.) If not for the very rare happenstance of hands-on support, she'd just be left to struggle on her own, offering a screaming baby the breast 8 times a day and using the hand pump she got in the hospital to get what she can.

This is breastfeeding support in our country, to the most vulnerable moms who need help the most. This is why we need to talk about the public health risks of seeing formula as a perfectly good fall-back. This is totally unfair to mothers who WANT to breastfeed, who are working hard to breastfeed, and who do not have the resources to get the help they deserve.


*Bonus AmeriCorps story: Our supervisor did not love us doing home visits - you wouldn't either, if you were an experienced midwife with strong maternal instincts, in charge of a group of naive but enthusiastic young women. She approved home visits only in very specific circumstances and with lots of warnings. We also had to call when we got there and call when we left safely. Like I said, strong maternal instincts. So one of my teammates and I went to do a home visit one day after lots of dire warnings and promising to call. We are primed to be cautious. We get there and it's just mom and baby home. We start helping her... and her boyfriend walks in just home from work - with a six-pack of beer. Immediately we both get a little anxious. This is what our supervisor was most concerned about - boyfriends/husbands/other men around who would give us a hard time or see us as a target. We're having trouble getting the baby latched (all the while keeping one eye on the guy doing stuff in the kitchen) and we suggest to mom that she pump a little to get the milk flowing. Her boyfriend leaps into action, assembling the breastpump, bringing it to her, and then sits beside her, asking us a lot of concerned questions about how the baby is feeding. So much for our paranoid fantasies!


**For a long time I wondered about that - how could people only have enough money for one bedroom, but still enough to have a huge expensive TV? - until one of my AmeriCorps teammates explained to me that buying expensive electronics was how many people in South American countries keep liquid assets. Think about it - if you don't or can't get a bank account, how can you make sure you can get cash if you need it, without actually keeping all that cash on hand? One way is to buy something that will be easy to re-sell quickly. It's not a great investment, because it will depreciate instead of appreciate, but people only have so many options. I really appreciate the work that community-based organizations and credit unions do to help teach people about banking and make those options more accessible.

Which growth chart to use?

In the past few months, I have happened to talk with three different mothers who told me about their breastfed children's growth "slowing down" around 4 months - the baby's weight percentile dropping and the baby slipping down the growth curve. Somewhat fortunately, all of these mothers were told by their pediatricians that this was "common" or "normal", and none of the pediatricians pushed supplementation or were very aggressive about starting solids.

Unfortunately, while the pediatricians were right not to change the baby's diet, they were wrong in giving moms the impression that their child's growth slowing - while perhaps "common" - was "normal". In fact, they were wrong in giving moms the impression that it was slowing at all! And once that idea is planted in a mother's head, it's hard to erase the underlying anxiety she might have, despite reassurance to the contrary, that her milk is no longer quite keeping up with her baby's needs.

The fact is, many pediatricians' offices still use growth charts developed in 1977, based on a small sample of babies in Ohio who were primarily formula fed. Similarly, even the 2000 Centers for Disease Control (CDC) growth charts are based on a sample of mixed breast/formula feeders. Formula fed babies grow more slowly than breastfed babies in their first few months of life, then begin to grow more quickly than breastfed babies. When we chart breastfed babies on the formula fed growth chart, it makes breastfed babies look nice and high on the chart for the first few months, and then start to look like they are faltering.

What does it look like when breastfed babies are tracked on charts that accurately reflect their growth? To do that, the newest World Health Organization (WHO) growth charts are a far better choice than any of the CDC charts. The WHO charts are based on a worldwide sample of infants who received optimal breastfeeding and complementary feeding.

This article from the Journal of Nutrition does an excellent job of discussing some of the differences between the CDC and WHO growth charts. They have several great illustrations as well to help you visualize how the growth charts differ:

This chart shows the difference between weight-for-age curves in boys ages 0-60 months. You can see how around 4-6 months, the CDC chart line crosses over the WHO line and generally stays above - sometimes quite high above - the WHO line up through age 5.

I like this chart even better, which shows how an average infant from the WHO sample would track on each chart. A baby who tracks normally on the WHO chart (staying fairly even in growth after an initial drop) looks very different on the CDC chart: after an initial rise the baby appears to slowly fall down the growth curve from the age of 2 months on.

One of the moms I talked to went back and plotted her children's growth on the WHO charts and was pleased to see that all of a sudden, instead of slipping down the chart, they were tracking beautifully along the growth curves. She knew all along that they were healthy and feeding well, but it's always nice to have it confirmed that the charts were wrong - and mom was right.

Happily, the CDC is now formally recommending that all clinicians switch to the new WHO growth charts for ALL infants and toddlers up to 2 years of age. (Note that this means not just breastfed babies - the CDC recognizes that those charts reflect optimal infant growth, and that the more rapid growth of formula fed babies is a potential cause for concern.) If you have kids, do you know which charts their pediatrician or family doc is using? Do your care providers know about the CDC encouraging the growth chart switch?

P.S. Let's also keep in mind the relative importance of growth charts. I've had some great conversations in breastfeeding-related courses about the overall silliness of the American obsession with having every baby "above average" on the growth charts. It's as if scoring 95th percentile on the growth chart is like getting an A on an important test. Growth charts are tools to be used in conjunction with other indicators of a baby's health and intake, they do not reflect the normal growth of every child, and it is just as normal and healthy for a baby to consistently be in the 5th percentile as in the 95th. Phew! I've said my piece.

Linky goodness: to VBAC or not to VBAC, birth videos, and more!

Time to clear out the starred posts in my blog reader! Sorry, some of them are a few weeks old but of course, still great:

Robin Marty of RH Reality Check on the many reasons she's choosing an elective repeat c-section over a VBAC attempt.

Birth Sense introduces you to the handsome, charming Dr. Justin Case.

Video of baby born in the caul, via Homebirth: A Midwife Mutiny.

Video of frank breech home birth via Gloria Lemay.

Dou-la-la channels Don Draper in explaining why those nice formula companies are so darned excited about breastfeeding.

Why African Babies Don't Cry, via Blacktating.

Mom's Tinfoil Hat linked to a post on abortion and parental notification laws that, very sadly, is no longer up (the author decided to make posts about her work private - I struggle with walking the same line, and totally understand). However, you can still read an excerpt and a long comment from the author in MomTFH's post.

Not birth-related, but something that really touched me to see today: Dan Savage's It Gets Better Project: a collection of videos of adults telling gay teenagers that high school ends and their lives will improve. Read an interview with Dan Savage here, including the reason he decided to start this project.

Fewer Swedish babies breastfed, still way more Swedish babies breastfed than American babies

Every so often...okay, not often, but once in a blue moon...my Swedish skills come in handy. And today I got the chance to put them to use, reading this report from the Swedish government on changes in breastfeeding rates from 2004 to 2008. While their recent decreases in breastfeeding are a problem (drops of more than 4% for some indicators) I was also struck by how insanely high most of their numbers seem to someone from the U.S.:

Exclusive breastfeeding at 1 week: 85% (down 4.3% from 2004)
Partial breastfeeding at 1 week: 12% (up 3.5% from 2004 - so there seems to be more early supplementation going on)
Adding these up, only about 3% of babies at one week are exclusively formula fed

Contrast this to the U.S. where over a quarter of infants are supplemented with formula before 2 days.

The drop becomes more pronounced the older children are (makes sense with an increase in early supplementation). At 6 months, 66.5% children are still exclusively or partially breastfed, down 6% from 2004. (But still, compare to 43% in the U.S.)

The one data point I found contradicting this pattern was breastfeeding to a year. While this report doesn't give national numbers, it notes that any breastfeeding at 12 months ranged from 11-22% in different regions of the country. That actually compares favorably in the U.S. with about 22% of babies being breastfed at 12 months here. It seems counterintuitive, given that one of the great supports Sweden gives to nursing mothers is their year of "mammaledig" - maternity leave. It makes me want to ask my Swedish friends more about how long they planned to breastfeed and when the cultural expectation is that they'll wean.

The researchers note that they don't know why breastfeeding is decreasing, because it hasn't been studied yet in relation to social and demographic factors. I've heard that "pappaledig" - paternity leave - has been increasing in popularity and fathers are increasingly taking a larger share of the time off. Could this be a contributor? Again, I'll have to investigate...

Volumes: a huge problem

The response to my last post on "los dos" pushed me into finally finishing this one! The volumes given to babies are a huge part of what makes "los dos" so problematic, but are a problem on their own as well. We don't know exactly why breastfeeding is protective against obesity, but a big part of it may be the part with the breast. It's harder (although by no means impossible) to overfeed a baby at the breast. When you're giving a bottle, it's much easier to overfeed a baby and to override their own feelings of satiety/being full by persuading them to just finish what's left in the bottle, or what we think they should be taking.

This problem, unfortunately, frequently starts on the first day of a baby's life. Have you ever seen the belly balls made by Ameda? I think they are a nice way to visualize the size of a newborn's stomach on days 1, 3, and 10. Day 1 is a shooter marble, representing 5-7 milliliters(ml), and Day 3 is a ping-pong ball, representing 22-27 ml. As a frame of reference for those of us not used to metric, 1 fluid ounce = 30 ml, and 1 teaspoon = 5 ml.

These are tiny volumes, as is appropriate for tiny babies with tiny stomachs designed to handle small volumes of colostrum that empty quickly (the gastric emptying time of breastmilk is about half that of formula).

These volumes mean that at one feeding, even on Day 3, a baby should be getting a maximum of 1 ounce.

And yet over and over in the hospital and out of it, I am absolutely boggled (and sometimes horrified) by the volumes that people are able to push to a baby via bottle. I walked into a room the other night and a mom had breastfed her 1-day-old baby on both sides, and THEN given him 40 ml via bottle. All of us routinely see parents who are able to get babies to take 45 ml or more at nearly every feed. Even at day 3, these babies are literally eating double what they're supposed to.

What happens when babies get fed such huge volumes? First of all, they spit up. Give a brand-new baby a 10 ml feed (and remember, this is just 2 teaspoons!) and you may find most of it spilled down her front. It can be scary for the parents and probably doesn't feel that great to the baby.

Second of all, they don't eat. New babies forced to take one huge feed may not eat again for the rest of the day, spitting up constantly with distended abdomens. Babies consistently getting supplemented after breastfeeding, even with smaller volumes, take longer to wait for the next feed -- maybe 4-5 hours instead of 2-3. Physiologically, this isn't sufficient to establish a good milk supply in most women.

Third of all, they get hungry. Forced to take huge volumes over and over again, they start expecting huge volumes. Mom's colostrum can't possibly keep up, which leads to a fussy baby, which leads to more supplements, which leads to less breastfeeding, which leads to lower supply...you see where this is going.

Huge volumes are one of the banes of the hospital LC's existence, as far as I'm concerned. And yet it's so hard to address.

I don't want to be the mean LC who tells the parents they just overfed their baby and doomed breastfeeding, but I do want to educate appropriately on volumes. I want to tell parents that this is too much for a baby's stomach, and that it can create problems with breastfeeding. I want to convince the parents that such huge volumes are a bad idea.

Unfortunately, the babies don't cooperate.

Parents seem to expect a baby who takes a large feed quickly and then sleeps soundly for at least 2 hours and preferably 3 or more, and overfed babies do this very well. "Baby doesn't wake up to feed as often" doesn't really sound like a problem to them. And yet once I cross the line into warning her "You can compromise your milk supply" that risks mom hearing what she probably already believes, which is that she won't produce enough milk. AND I hear the eye-rolling message boards of the Internets in my head. ("The lactation person in the hospital told me if I gave my baby ONE BOTTLE of formula, I would NEVER produce enough milk! Boob nazi!")

Parents also expect that if the baby is hungry, she/he will keep sucking, or will be willing to take a bottle back into his/her mouth. Overfed babies will most certainly keep sucking if they have a constant flow of liquid down their throat (the bottle will flow by itself without any help from them) -- in fact, it's hard for them to stop because then they would choke -- and they have a firm stimulus in the back of their mouths. They will do this regardless of their own feelings of hunger or satiety. You can also often get an unwilling baby to accept a bottle nipple back in if you play around long enough (less frequently true for the breast).

I know that responsiveness to hunger/satiety cues is an issue identified, and under research, by people out there in the infant feeding world. I think a key piece is being able to interpret NORMAL newborn behavior (fussy does not always equal hungry! frequent waking is not pathological!) and respond to a baby's cues instead of overwhelming them.

What do we do at the hospital to solve this? We try so hard to educate everyone at their first hi-I'm-the-LC visit if they are planning to do any supplementation. (Obviously we also try to educate them about exclusively breastfeeding, but this is harm reduction.) This takes different approaches, generally from the "your baby's stomach is only this big!" school of thinking.

I've also started taking a more direct route. If I'm the one bringing the bottle (you can't win every time) I pour out everything but what they baby should take at that feeding. (That a 2 oz bottle is considered the standard for a newborn nursery just shows how insidious the formula industry is). We would not give 4 pain pills to a mom and say "but only take one". Neither should we hand her a 60 ml bottle and say "but only give 10" especially because if baby keeps sucking they interpret that as "still hungry". This also prevents the practice of re-using the same bottle for multiple feedings (this happens all the time even though the bottle clearly says it should be discarded after an hour.)

It also helps to at least ask moms to give supplements via a supplementing tube at the breast (you can rig up a cheap, easy one with a 10 ml syringe and a 5 french feeding tube) or a similarly-sized dental syringe. The 10 ml syringe makes that amount look like a large amount, we have parents push it very slowly, and it at least keeps baby stimulating the breast.

I'm trying to get the nurses to do the same although this is more challenging -- I am winning a few interested parties over to trying it. Unfortunately, not every nurse sees these volumes as an issue, which leads me into my second group of overfeeders: the hospital staff.

Oh man, I wish with all this I could say that it was only the parents. But no, if a partially-breastfeeding (or even exclusively formula feeding) mom has asked baby to get a bottle in the nursery, there are nurses who will give 25 ml on Day 1 just like anyone else. (Or more, to the point of pathological...) One of the nurses who is now an LC told me it used to be a point of pride for her that she could get babies to finish the bottle, and I've heard similar stories elsewhere from nursery nurses -- getting that baby to eat who just wouldn't was (and sometimes still is) a valued skill, and getting them to eat a lot meant full, happy, healthy babies filling your nursery.

I will say, not all nurses do this! They will come to me and say "she asked me to give a bottle so I only gave him 10 ml, why don't you go see if he's hungry again and wants to breastfeed" or "she asked me to give a bottle before she came upstairs from L&D but I just made his bath take an extra long time, maybe you could get her started breastfeeding". They tell parents independently not to give too much and that it interferes with breastfeeding, or set them up with a dental syringe with a tiny amount of formula if they insist on supplementing, and they don't hand them 3 or 4 bottles at a time. Thank you, wonderful nurses!

How to solve this problem in the long-term? I heard the prolific and very smart breastfeeding researcher Kay Dewey speak last year, and she talked about her research trying to teach parents to interpret feeding cues correctly. Unfortunately, that education (done with WIC participants) was found to be ineffective at reducing overfeeding. It sounded like their next step with that research, to expand the education from just feeding cues to teaching parents how to interpret their babies' cues generally, was going much more successfully. I'm looking forward to reading more about it as they complete their research. I think it's the right direction to go in -- I believe a big part of the issue with volumes is the unrealistic expectations for "satisfied" baby behavior. Getting it to parents, however, will be a big step and take a long time.

In the meantime, what do you do to discourage parents from giving big volumes? Did you know how much babies were supposed to take in their early days?

"Los dos" and an awesome new campaign

From the moment my AmeriCorps team started doing breastfeeding education and support in Denver, we came up against "los dos" (literally "the two", better translated as "both"). The majority of our clients, particularly at newborn visits, were Hispanic (largely from Mexico). When we asked them if they were breastfeeding/planning to breastfeed, the answer was almost invariably "los dos" - both breastfeeding, and giving formula by bottle.

I've had a post coming about this for a while - it's a very frustrating thing to deal with and as an inner venting strategy I've composed this post many times in my head.

Why so frustrating? Well, at my current work I see that often "los dos" begins in the hospital. Moms tell me "es que no tengo leche" - "It's that I don't have any milk" - even when I help them hand express abundant colostrum, they don't believe that their colostrum will be enough to sustain baby until their milk comes in. This supplementation often tends to feature HUGE volumes given by bottle (think 1.5 ounces on Day 1, with a baby whose largest feed should probably be 1/3 of an ounce. There is a separate, also long, post about volumes coming - not just about Hispanic moms either.)

Babies get used to the fast flow and firm nipple of the bottle, and they come to expect huge volumes which colostrum cannot provide the first few days. They become fussy at the breast and the mother tells me "es que no quiere el pecho" - "he doesn't want the breast" or "he's refusing it". There seems to be a perception (and believe me, this needs a lot more research) that a large percentage of babies just don't want the breast - with no specific cause or cure - and that if not, you should just give up and bottle feed.

(This, as a side note, is why I think all the people who say nipple confusion is a "myth" are full of it. Over and over again at the newborn clinic in Denver, we'd hear "es que no quiere", slap a nipple shield on, and baby would nurse happily with mom's newly-in milk supply and a nipple that felt more like what they were used to.)

If baby doesn't become nipple preferenced (which some manage to avoid) then continued supplementation often starts to affect milk supply. Mothers tell me they weaned their last babies at one or two months because "no tenía leche" - "I didn't have milk", and "se desesperó" - "he got frustrated" (although used slightly differently it would be mean "to lose hope" which seems so fitting for those babies!)

There seems to be a strong emphasis on babies getting fed a lot, as often as possible, and it's hard to convince/convey to many Hispanic mothers that their babies will get MORE breastmilk if they supplement LESS. Instead, the response to this frustration and dropping milk supply is of course to offer more bottles and fewer breastfeedings. Baby quickly learns where the real supply is coming from and the mother tells me that with her last baby after a few weeks, "no quiso el pecho" - "he refused the breast".

To me all of this is particularly notable as Hispanic moms almost universally tend to want to breastfeed, and when given cooperative babies and milk supplies will generally nurse for a long time - particularly as many stay home to take care of their children. Moms who give up on a nipple preferenced baby will happily nurse the ones who do tolerate "los dos" for a year or two. While many Hispanic moms have yet to make the connection between supplementation and early weaning, I think most of them would prefer to breastfeed longer.

So why is this connection not made? Why is there so much supplementation and so much expectation of "no quiere"? Almost every night at work I dream of rustling up an MPH student to do some focus groups with Hispanic moms on what it means to them to "have milk", for the baby to be satisfied, what they think formula adds to the baby's satisfaction/health, what it means when the baby "doesn't want" the breast, how milk supply is perceived to be driven, etc. etc.

That's still in fantasyland though, so I am so excited that the Massachusetts Breastfeeding Coalition has a new campaign going - the first that I've heard about - targeting "los dos". (Interestingly, they call it "LAS dos" which I've never heard, but maybe it just varies from person to person.)

One poster for the ad campaign has a picture of a baby and a speech bubble saying (in Spanish): "Both (lit. "the two")? Mama, you already have the only two I need! If you give me formula, you won't make enough milk for me." Below it says "Give me only the breast."

Another has the same dialogue with two smiley-faced breasts and a frowny-faced bottle - I love the happy breasts!

And check out the fun story behind the slogan at the Motherwear Breastfeeding Blog!

Will it work? Will moms like it? I hope to hear more about this... and if any MPH/anthropology/sociology/etc. students out there want to get a little qualitative research experience, PLEASE consider this topic!!

Two stories from China

First: Female babies in China grow breasts as a result of drinking hormone-tainted formula:

The official China Daily newspaper reported today that medical tests indicated that the level of hormones in three 'test case' girls, ranging in age from four months to 15 months, exceeded those found in the average adult woman.

All the babies who showed symptoms of the phenomenon were fed the same baby formula.

Second: Chinese Formula Maker Prepares for Stock Offering:

As Yashili moves toward a public listing, potential investors will be keen to see how much market share it has clawed back from foreign brands, which Chinese consumers came to see as safer during the scandal.

Yashili's sales and profitability have recovered and overtaken pre-melamine scandal levels. But it has had to raise prices to cover the cost of the cleanup, a common theme across the industry, according to Mr. Siewert.

The factors driving growth in the industry are the growing affluence of the Chinese and a declining breast-feeding rate.

In 1998, 76% of mothers exclusively breast-fed children, according to Unicef, but that dropped to about 50% by 2008 as they sought to supplement their babies' diet.

The Chinese infant-formula market is the world's second-largest, surpassing Japan, and is expected to overtake the U.S. shortly, according to a report by Oppenheimer. The market is expected to grow at a double-digit rate in the next five to 10 years, the report added.

BBC doesn't believe lack of breastfeeding kills babies in developing countries

Morgan Gallagher, breastfeeding advocate in the UK, writes about how she was kicked off an interview on the BBC world service for saying that formula feeding kills babies in Africa.

Here's an excerpt, when the producer tells her she needs to stop criticizing formula:

...she cut me off and said she understood I was against formula, and pro-breastfeeding, but formula wasn't the issue. I was biased, and they couldn't have that bias on air. I said they had the bias, not me, and this was the World Service, and they had a duty to act globally, and not act as if the whole discussion was taking place in West London. How could they ask a women in KENYA if she would support formula feeding?

It consistently blows my mind how the media is able to cast health effects breastfeeding vs. formula feeding as a matter of opinion even when the discussion is happening re: the developed world. It's beyond belief that the BBC World Service would try to apply this already false construct to the developing world, and would throw off a participant for being willing to say that babies die in the developing world because they are not breastfed. Because, you know, she's "biased". I guess I'm "biased" towards breastfeeding too, particularly for children in the developing world. I am also "biased" towards those children getting food aid, vaccines, and clean water, as those also improve survival rates. Oh, wait - those are considered facts. Strange.

Ugh. Working nights is making me cranky, and this is not helping!

Why do babies get supplemented in the hospital? A story from my first week on nights

While I have told myself I was going to try to pick up the posting rate in June, this week was my first doing night shifts (11 pm - 7 am) on lactation support at the hospital where I've been training to be an LC. I feel pretty comfortable there at this point, but it feels so strange to have my own electronic charting ID and not have to wait for anyone else to log me in - before, we were being supervised by the LCs and so I would chart on their accounts under their supervision.

Obviously, I've been a little anxious about whether the night nurses would be welcoming, whether people would be willing to call me - basically whether I'd have any work at all! While all the staff I've talked to so far have been nothing but happy and excited to have lactation support available, the first night was really quiet. I saw a few people in the first couple of hours, then sat around, and then things picked up from 5 am - 7 am when people started to wake up and call for assistance. I told myself that the census was low, and staff were still getting used to me being there, but I wondered if every night would be so quiet. The big hope was that having someone overnight on lactation would help prevent a lot of the bottles and supplementation that happens at night. Was I going to be able to do that?

The following night answered that question for me. I basically never sat down except to chart. I spent at least an hour with in three different rooms. And my big victory was helping keep a hypoglycemic baby from being unnecessarily supplemented. The cut-off for hypoglycemia in the newborns here is 45. The nurse caught me in the nursery and said she had tested twice, baby was just below the cut-off and heading in the "wrong direction". To the nurse, formula seemed like a medical necessity at this point. She asked if maybe I could do it at the breast. When I came into the room, though, mom was crying - she didn't want to supplement. I offered to handle the situation from there and the nurse said that was fine - she left us to it. The mom told me the baby had been hungry and about to feed, right before the nurse had come in and taken him for the blood sugar testing. I said "Well, if he's hungry, he can nurse and if he nurses well, he won't need any formula."

So, we put the baby to breast - and this baby was, indeed, very hungry and nursing fairly well. Still, I was anxious - I did not want to screw this up, I was going to get all the colostrum into that baby that I could. The nurse had brought a couple of dental syringes for the formula. I took one and popped the stopper out, and asked mom if we could hand express into it from the other side and supplement the baby with expressed colostrum. Mom said OK very readily and wow, she had plenty! I was boggled to think this baby could have ended up with formula with so much colostrum available. The mom's sister was spending the night to help her out and happily assisted with hand expression (with mom's agreement, of course) - it was so nice to see such good family support! Who says other family members can't participate in breastfeeding?

Between nursing and supplementing, by the end of the nursing session I was having to take him off and wake him up repeatedly, and he would fall asleep as soon as he got back to the breast. This kid was full. (But I was not going to let him go to sleep without getting every last drop he could!) Finally, I put him skin-to-skin with mom (also good for blood sugar!) and called the nurse to tell her "went great, no formula needed!" And you know what? The nurse was totally fine with that. She gave the baby a full hour before rechecking his sugars and - yay! - baby was back above the cut-off - "heading in the right direction". The nurse was actually very gracious and helpful about all of this, and I realized after talking with one of the other LCs that it's not a "breastfeeding is bad" mentality at all on the nurses' part - this nurse just wanted to fix the blood sugar, and the formula could be the fix, or my help with breastfeeding could be the fix. Of course, since I'm not always there, it would be nice if this experience helps her have more confidence in the future with putting baby to breast as the first line of treatment. But one step at a time!

After all this drama about avoiding what probably would have been just several milliliters of formula, you may be wondering, what's wrong with just a little supplementation? Just to get the baby's blood sugar up - then they could go on breastfeeding, no problem. And I think it's a fair question. It doesn't seem like a single bottle would do that much harm. And yet we know that babies who are supplemented - even a single bottle - in the early days tend to have shorter durations of both exclusive and any breastfeeding. And is that so surprising? After all, we say to mom "You need to supplement with formula because your baby's blood sugar is low", what is the message we are sending? "Your milk has not been feeding your baby adequately, and it will not feed your baby adequately; we cannot trust that it is there in sufficient amounts and/or that your baby can get enough of it." Any wonder that these moms go on to mistrust their ability to nurse their babies? Additionally, even just a little formula affects baby's gut flora for weeks, changing the balance of beneficial flora that exclusive breastfeeding establishes (for more information on all of this, see this article by Marsha Walker, particularly the section "Some Cautionary Words About Supplementing with Formula").

Does all this mean we should not give formula when medically necessary? Of course not! But as you can see, medical necessity in this situation was somewhat blurry. With no breastfeeding support, it's possible that this baby would have needed to be supplemented with formula. But in the end, it turned out not to be necessary at all. Babies get those bottles of formula not necessarily through malice, but because of staffing issues, longstanding habit, and lack of education and lack of trust in breastfeeding. They get formula without the understanding of the risks of "just a little bit".

What can you do to avoid unnecessary supplementation in the hospital? A few things:

1) Prepare yourself for breastfeeding - read, take a class, attend La Leche League meetings - boost both your knowledge and your confidence.

2) Choose a certified baby-friendly birthplace - this won't eliminate the possibility of unnecessary supplements, but it will greatly decrease them!

3) Make sure breastfeeding is going well - let the staff know you are committed to breastfeeding, ask for a lactation consult, and solicit outside help from La Leche League or a lactation professional if you need to. Yes, those people can come visit you in the hospital!

4) Surround yourself with family and friend support. Maybe the sister-in-law who keeps asking whether the baby is "too hungry" is not the person to spend the night with you!

5) Be ready to advocate for yourself if needed, and have all that knowledge, preparation, and support ready. I saw another mom a few months ago who confronted the same night-time pressure to supplement for hypoglycemia. She insisted that she get a chance to breastfeed first and, lo and behold, that baby's sugar came up too. Self-advocacy is not always easy (and unfortunately not always successful), but it is very important!


So that's my first dispatch from nights! I'm currently in recovery from the crazy schedule-shifting and ready to get back to regular sleep patterns for a few days. Any nurses out there have tips on shifting back and forth? I'm used to doula work where you can't plan it - you just power through and then sleep it off over the next couple of days. Tips for actually planning your night shifts would be greatly appreciated!